Integrating health responses to family adversity and intimate partner violence is crucial
Authors: Janet L Fanslow
Journal: The Lancet Public Health (2023)

The 2002 World Report on Violence and Health provided the foundation for global recognition of violence as a health issue.1Krug EG Dahlberg LL Mercy JA Zwi AB Lozano RE World Report on Violence and Health. World Health Organization, Geneva2002Summary Full Text Full Text PDF Google Scholar Since then, knowledge of the health consequences of exposure to violence has proliferated, with evidence linking exposure to child abuse and neglect and other adverse childhood experiences (ACEs) with many of the leading causes of death2Gilbert LK Breiding MJ Merrick MT et al.Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010.Am J Prev Med. 2015; 48: 345-349Summary Full Text Full Text PDF PubMed Scopus (398) Google Scholar and increasing evidence of the effects of intimate partner violence (IPV) on chronic physical and mental health problems.3Mellar BM Hashemi L Selak V Gulliver PJ McIntosh TK Fanslow JL Association between women's exposure to intimate partner violence and self-reported health outcomes in New Zealand.JAMA Netw Open. 2023; 6e231311Google Scholar Policy and guideline changes have paralleled this emerging knowledge with varied success. The importance of recognising, responding to, and preventing ACEs throughout health and other systems has increased, driven in part by championship from agencies like the Centers for Disease Control and Prevention.4Centers for Disease Control and PreventionAdverse Childhood Experiences (ACEs).https://www.cdc.gov/violenceprevention/aces/index.htmlDate accessed: May 25, 2023Google Scholar Other calls, like WHO recommendations for health-care provision for women who have experienced IPV or sexual violence5WHOHealth care for women subjected to intimate partner violence or sexual violence: a clinical handbook. World Health Organization, Geneva2014Google Scholar have had more mixed results. For example, despite guidelines advocating for routine enquiry (screening) for IPV within health-care settings, IPV screening rates remain low (eg, 8·5% within primary care settings) and the rates of successful identification of IPV are even lower.6Perone HR Dietz NA Belkowitz J Bland S Intimate partner violence: analysis of current screening practices in the primary care setting.Fam Pract. 2022; 39: 6-11Crossref PubMed Scopus (1) Google Scholar Given that 27% of women globally will experience IPV in their lifetime,7Sardinha L Maheu-Giroux M Stöckl H Meyer S García-Moreno C Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018: a systematic review.Lancet. 2022; (published online Feb 16.)https://doi.org/10.1016/S0140-6736(21)02664-7Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar health-care systems are missing opportunities to respond to this important issue. Currently recognition of how proposed health-care responses to ACEs and IPV could be integrated is limited. In this issue, Shabeer Syed and colleagues8Syed S Gilbert R Feder G et al.Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England.Lancet Public Health. 2023; 8: e520-e534Google Scholar present a study exploring how ACEs and IPV may co-occur, using linked electronic health records to assess the prevalence of family adversity and its associations with indicators of IPV. They developed a population-based birth cohort of almost 130 000 children and parents and linked information from mother–child pairs and mother–father–child triads with data from general practices, emergency departments, outpatient visits, hospital admissions, and mortality records. They assessed 33 clinical indicators of family adversity, then estimated the probability of IPV associated with each adversity. Although overall recording of IPV in the clinical records was low (an estimated 2·1%, 95% UI –0·13 to 6·0, of the sample), the prevalence of family adversity was high, with 41·2% having a record of any family adversity between 1 year before and 2 years after birth of the index child. The authors found that all family adversities were significantly associated with IPV, and that the probability of IPV increased with the number of family adversities experienced (eg, 4·4 per 100 children and parents among those with one adversity, 15·1 per 100 children and parents among those with three or more adversities). The authors then reinforce and extend our knowledge of health consequences associated with IPV by comparing the prevalence of parental mental and physical health problems among families with and without IPV. The study by Syed and colleagues8Syed S Gilbert R Feder G et al.Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England.Lancet Public Health. 2023; 8: e520-e534Google Scholar is both elegant and thorough and has strong clinical implications for targeting screening for IPV among families with adversities. This approach might be more fruitful in terms of IPV identification than recommendations for universal screening, capitalising on the relative enthusiasm of health-care providers for identifying and addressing ACEs that we have not seen for identifying and addressing IPV. The strategic value of this approach is clear if it allows more health-care providers to recognise and respond to violence, and the practical value will follow if it opens more pathways for families to connect with needed support services. The caution is that it does not become another source of systemic bias, in which we only see IPV and child abuse and neglect among families that are already experiencing adversity. Having an integrated assessment and response for ACEs and IPV within families is sound. This strategy taps into current policy priorities identified by the UK government9HM Government. The best start for life. A vision for the 1,001 critical days. London: The Early Years Healthy Development Review Report. 2021.Google Scholar and aligns with recommendations for health-care providers to integrate responses to child abuse and neglect and IPV that are present in New Zealand.10Fanslow J L Kelly P Ministry of HealthFamily Violence Assessment and Intervention Guideline: child abuse and intimate partner violence.2nd ed. Ministry of Health, Wellington2016Google Scholar However, even with the proliferating evidence about the importance of ACEs and IPV to health, there remain crucial gaps in how health-care providers identify and respond to these issues. Targeted IPV screening among families experiencing adversities has potential to yield more frequent identification of IPV, but this will only be realised if strongly supported by systemic changes. These changes need to start early, such as through embedding knowledge of effective violence and trauma-informed health responses in our health curricula, an area in which there are current gaps.11Ambikile JS Leshabari S Ohnishi M Curricular limitations and recommendations for training health care providers to respond to intimate partner violence: an integrative literature review.Traum Viol Abuse. 2022; 23: 1262-1269Crossref PubMed Scopus (5) Google Scholar Following IPV identification with strong referral and wrap-around support for individuals experiencing IPV and associated family adversities will require investment in system change12World Health OrganizationStrengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers. World Health Organization, Geneva2017Google Scholar and will need to engage public health leaders and managers in courageously tackling these crucial issues. I declare no competing interests. Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in EnglandTwo in five of the children and parents presenting to health care had recorded parental mental health problems, parental substance misuse, adverse family environments, or high-risk presentations of maltreatment in the first 1000 days. One in 22 children and parents with family adversity also had recorded IPV before age 2 years. Primary and secondary care staff should safely ask about IPV when parents or children present with family adversity or health problems associated with IPV, and respond appropriately. Full-Text PDF Open Access